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6. A charge nurse in a long-term care facility is preparing to administer noon
insulin to a client. The nurse observes that the assistive personnel (AP) has no
documented the client's blood glucose level. Which of the following actions
should the charge nurse take first?
Determine if the AP has completed the assignment.
7. A client is scheduled for an outpatient colonoscopy+ which of the following
actions is a nursing responsibility in the informed consent process?
Verify that there is a signed and witnesses consent form in the client's chart.
8. A nurse smells alcohol on the breath of an assistive personnel CAP) during
report. Which of the following actions should the nurse take?
Report the situation to the nurse manager.
9. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of
the following clients is an appropriate assignment for the nurse to accept?
A client who had a cesarean delivery 24hr ago.
10.A nurse in a provider's office is collecting data from a parent of an infant who is
being screened for cystic fibrosis. Which of the following supports a diagnosis
of cystic fibrosis?
Frothy stools.
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11.When caring for an assigned group of clients, the nurse should wear gloves
when
Performing oral hygiene.
12.A nurse is preparing a client for surgery. The client tells the nurse that he is
concerned about the safety of a large sum of money in his wallet. Which of the
following actions is appropriate for the nurse to take?
Contact security personnel to place the money in the facility safe.
13.A nurse is caring for a client who is receiving heparin. Which of the following
is the appropriate route of administration?
Subcutaneously.
14.A nurse is reinforcing teaching about car seat safety to the parents of a
newborn, The nurse should instruct the parents to place the car seat in a?
Rear-facing position in the back seat.
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15.A nurse is caring for a client and recognizes the client's rights to confidentiality
have been breached in which of the following situations?
A hospital risk manager includes information from a client's medical record
in
16.A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days
ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on
the affected leg. Which of the following actions should the nurse take?
Notify the charge nurse of the finding.
17.A nurse is caring for a full-term newborn who was circumcised 6 hours ago,
which of the following findings indicates that the newborn is experiencing
pain?
Furrowed Brow
18.A nurse is reinforcing teaching with a client about organ donation. Which of the
following client statements indicated a need for further teaching?
"My doctor should decide if my organs will be donated."
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19.A Client who is prescribed metoprolol (Lopressor) for hypertension tells the
nurse, "I don't want to take this medication because it makes me tired all the
time." Which of the following is the appropriate response?
"Let's talk with your doctor about other options."
20.A nurse is preparing to administer an IM injection to a client. To reduce the risk
of needle stick injury, the nurse should?
Dispose of the used needle immediately in a puncture-proof sharps container.
21.A Nurse is contributing to the discharge plan for a client following surgery.
Which of the following findings indicate the need for an interdisciplinary care
conference?
The client requires assistance to pay for dressing supplies.
22.A client who is 24 hour postoperative suddenly develops chest pain, dyspnea,
anxiety, diaphoresis, and cough. Which of the following actions should the
nurse take first?
Elevate the head of the client's bed.
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